VRS Referral

You may complete our Referral Form below, or download and return it by email to fredfrey@vrsdm.com or by fax to (802) 622-4327.

Download as MS Word Document OR Adobe PDF

Referred By

Insurance Carrier

Treating Physician

Employer

Service Requested

Initial Contact

Claimant

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Plaintiff's Attorney

If applicable

Defense Attorney

If applicable